1. Overview of Contraception Nupur Kumar DO, MPH May 22, 2006 Drew University PA Program

2. Facts In the US there are 63 million women aged 13 – 44 who may potentially use contraception 53% of the annual 3 million unwanted pregnancies occur in women who use contraception incorrectly or inconsistently Chance of pregnancy in 1 year of unprotected intercourse is 85% - available contraceptive methods can decrease this to 0.05% Counseling is the key!

3. Categories of Contraception Natural – Rhythm Method Barrier – Male and Female condom, Spermacide, Sponge, Diaphragm, Cervical Cap Hormonal – Pill, Patch, Ring, IUD, Depo-Provera Injection Permanent – Male and Female Sterilization Emergency Contraception – “morning after” pill

4. Prior to Initiation Pap Smear and Pelvic Exam Negative documented Pregnancy Test Informed consent with explanation of risks and benefits Explanation of method use

5. Natural Family Planning The Rhythm Method Identification of potentially fertile days each cycle when partners may abstain from intercourse Approximately a period of 6 days based on life spans of sperm (5 Days) and egg (1 Day) Based on assumption ovulation occurs on cycle day 14 +/- 2 days 9% Pregnancy rate in 1 year of “perfect” use or 26% with typical use

6. Natural Family Planning Other Methods I Cervical Mucus Method Mucus is more abundant and clear as ovulation approaches; after ovulation mucus is cloudy, thick, scant, or absent. Basal Body Temperature Body temperature rises 0.4 degrees F around time of ovulation.

7. Natural Family Planning Other Methods II Symtothermal Method Combination of Cervical Mucus and Basal Body Temperature methods with checking of symptoms like Mittleschmerz (mid-cycle ovulatory) pain and breast tenderness Ovulation Prediction Kit - OTC

8. Male/ Female Condom Widely and easily available Failure Rate Perfect Use - 3% Typical Use - 14% Side Effects – Latex Allergy Advantages Used in conjunction with another method to increase efficacy ONLY method decreasing STD/HIV risk

9. Other Barrier Methods Spermacides Include gel, cream, foam, film, and suppositories Must insert prior to each act of intercourse 71-82% effective Vaginal Sponge Wet and insert prior to sexual activity 68 – 91% effective Diaphragm/Cervical Cap Inserted prior to intercourse (up to several hours) Used in conjunction with foam or gel Needs to be fitted in medical office/clinic 86-96% effective, higher failure rates in patients with a history of vaginal delivery

10. Oral Contraception Combination Pill Pill taken at the same time each day Cycle of 28 days – 21 hormone containing pills and 7 sugar or iron pills Failure Rate Perfect Use 0.1% Typical Use – 5% Side Effects – breakthrough bleeding, nausea, breast tenderness, headache Advantages – decreased menstrual blood loss, decreased dysmenorrhea

11. Oral Contraception Progestin Only Taken daily within 3 hour period Based on 28 day cycle Failure Rate Perfect Use – 0.5% Typical Use – 5% Side Effects – irregular bleeding, breast tenderness, depression Advantages – no estrogen, decrease in menstrual blood loss and dysmenorrhea, okay in breast feeding

12. Seasonale Long Term Hormonal Contraception First extended Cycle birth control pill FDA approved in US Four cycles per year Increased spotting or breakthrough bleeding in first few months Practitioners have been manipulating monthly OCPs for years – this is a fixed package based on the same principle

13. Disadvantages of Oral Contraception Forgetfulness – 16% of users are inconsistent in taking the pill Estrogen Effects Avoid in older patients who smoke due to increased risk of thromboembolic events Increased side effects in estrogen sensitive patients Spotting/ breakthrough bleeding ( can try pill with lower dose)

14. Relationship of Oral Contraception and Cancer Meta Analysis of 79 long term studies showed excess of 151 cases of breast cancer, 125 of cervical cancer, and 41 of liver cancer. Also showed a decrease in 197 cases of endometrial cancer and 193 of ovarian cancer. NOT statistically significant! Any perceived risk declines after stopping the pill and no difference exists between users and nonusers after 10 years. Chemoprotective effect more prominent in those with family history – 5 year use associated with 50% reduction in uterine and ovarian cancers.

15. What About Acne? Most Combination Pills should be beneficial if contain estrogen and progestin with low androgenic activity Ortho Tri-Cyclen is the only FDA approved pill for the treatment of acne

16. Oral Contraception Side Effects I Nausea – subside after few cycles, can change to low estrogen/ progestin only dose Weight Gain – perceived: minimal or absent Galactorrhea – suppression of prolactin inhibiting factor, subsides within 3 – 6 months of pill discontinuation No Menses – change to higher dose estrogen for reassurance Teratogenicity – no increased risk of congenital malformation if pregnancy occurs

17. Oral Contraception Side Effects II Headaches – can take with food, later in the day, or switch to lower estrogen dose Mood Swings – some relation to vitamin B6 depletion, can supplement or lower estrogen dose Decreased Libido – due to reduced androgen production, decreased vaginal lubrication may be a factor

18. Absolute Contraindications to OCP Use History of thromboemboic events, CVA, Atrial Fibrillation, pulmonary hypertention Liver Disease Cancers of Breast and Liver Pregnancy Less than 6 weeks postpartum (combo pill only) Major surgery with prolonged immobilization Heavy smokers over age 35 (combo pill only)

19. Hormonal Patch Ortho Evra Patch Cycle of new patch weekly for 3 weeks then 1 patch free week to allow for menses Failure Rate Perfect Use – 0.7% Typical Use – 0.9% Side Effects – similar to OCP, skin irritation, decreased effectiveness in patients weighing > 198 lbs. (90 kg) Advantages – similar to OCP, less frequent dosing

20. Hormonal Vaginal Ring NuvoRing Insert for 3 weeks (continued use) then remove for 1 week for menses Failure Rate Perfect Use – 0.65% Typical Use – 0.65% Side Effects – vaginal irritation or discharge, headache Advantages – Similar to OCP, less frequent dosing

21. Intra Uterine Devices (IUD) 2 Available Types Paraguard: copper-containing, 10yrs, works by inflammation of uterine walls preventing implantation Mirena: Levonogestral System, 5 yrs, works by releasing hormone

22. Paraguard: Copper Containing IUD Procedure to insert: requires consent Failure Rate Typical Use – 0.6% Perfect Use – 0.8% Side Effects – heavy menses, dysmenorrhea Advantages – long acting, nonhormonal, no thinking once in Disadvantages – increased PID risk with string acting as vector, spontaneous expulsion

23. Mirena Levonogestral Intrauterine System Procedure to insert: requires consent Failure Rate Perfect Use – 0.1% Typical Use – 0.1% Side Effects - heavy menses, dysmenorrhea Advantages- no estrogen, easy to use, long term protection Disadvantages – increased PID risk with string acting as vector, spontaneous expulsion

24. Depo Provera Progestin only injection administered once every 3 months; may have delay in returning to fertility Failure Rate Perfect Use – 0.3% Typical Use – 0.3% Side Effects – Irregular bleeding or amenorrhea, weight gain, breast tenderness, acne, depression Black Box Warning – potential of decreased bone mineral density with long term use, must counsel patients about concurrent use of calcium and document! Advantages – no estrogen, long term

25. No Longer Used Lunelle – monthly injection, hormonally based, still available in Mexico Norplant Series of 5 hormone filled rods placed under the skin in fan shape Slow hormone release; protection for 5 years No longer placed but patients may present for removal: scar tissue may cause bleeding

26. On the Horizon: Male Hormonal Contraception Currently under investigation Suppression of gonadatropins and depletion of intratesticular testosterone which together result in arrest of spermatogenisis to induce azo/oligospermia (<1,000,000) Will likely be a combination of androgens and progestins

27. Male Permanent Sterilization Vasectomy Keeps sperm out of ejaculate by blocking vas deferentia: Traditional vs. no scalpel method Not fully effective for 3 months until existing sperm are “cleared out” of system Failure Rate 1/1000 in first year Cost $350 - $500 May be reversible in some cases but difficult and expensive procedure ($5000 - $14000) Risks: infection, bleeding, granuloma

28. Female Permanent Sterilization Bilateral Tubal Ligation Surgical closure of bilateral Fallopian Tubes 99% effective in the first year Higher risk of ectopic pregnancy if pregnancy does occur (due to scar tissue) Risks: bleeding, infection, anesthesia May be reversible but complicated and expensive Essure – no incision hysteroscopic method Metal coins inserted to block tubes Confirmed in 3 months by Hysterosalpingogram

29. Emergency Contraception Combination of estrogen-progesterone or progesterone alone Given up to 72 hours after intercourse Side effects: nausea & vomiting which can be minimized with concurrent administration of an antiemetic No effect after implantation nor any documented harmful effects to the fetus after emergency contraception has failed

30. Confidentiality and Minors Law states a minor may receive contraception without parental consent (Cal. Family Code 6925) Minor is defined as over 12 years of age Statutory Rape is defined as sexual activity with a partner age over 14 for ages 11 – 13 and over age 21 for ages 14 – 15 even if it is consensual. These are reportable situations.

31. Case 1 Ms. X is a 37 year old G1P1 who had a baby 2 months ago. She wants to use a birth control method that is safe for her baby as she is breastfeeding. She also wants something that is easily reversible as she wants to have another baby next year. She can’t use condoms as her husband has a latex allergy. What are her options?

32. Case 2 Mrs. Z is a 40 What are her options? year old G2P2 smoker with moderately controlled hypertention. She wants a safe, long term contraception method as she doesn’t want any more children and her religion is against abortion. She is in a monogamous relationship with her husband of 15 years and has no history of STDs. What are her options?

33. Questions????